Important Information First NameLast NameDate of Birth:DaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212621252124212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926Contact NumberReferred by:School:Grade:Teacher:Teacher Contact Number:Date of OT Assessment:DaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212621252124212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926Parents Marital Status:SingleMarriedDivorcedWidowedMarital Status is only required in order to ensure that communications are sent to both parties in the case of a divorce.First NameLast NameMother Contact Number:Mother Email Address:Father Name:Father Contact Number:Father Email Address:Closest Family / Friend:Name & Contact number in case of emergency.Identification of ConcernsHas your child been assessed by another Occupational Therapist?YesNoOT Name:Duration:Childs Age at the time:Has your child been assessed by another Specialist?YesNoE.g. Speech Therapist, Optometrist etc.Name:When?Child's Age:What do you feel are your child's strengths?What do you feel are your child's challenges?When were you first aware of these challenges?Mother's age at child's birthWas the pregnancy planned?YesNoBaby Birth WeightApgar Scores at 1 & 5 minutesHow many weeks gestation was baby born at?Birth MethodNaturalC-SectionC-Section Reason:ElectiveMedicalWas medication taken during the pregnancy?YesNoWere there any complications or unusual conditions during pregnancy? Please provide details.Please list medications takenWhere there any complications or unusual conditions during delivery? please provide details.Send Message
